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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> N 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> i P O BOX 2009, STOCKTON, CA 95201 /Ir1lZK I �Se/A97�Y BB�r� <br /> ENVIRONMENTAL HEALTH PERMIT EXPIRES 1 FROM DATE ISSUED <br /> PERMIT/SERVICES Yj (Complete in Triplicate) <br /> Application is hereby made.to San Joaquin County for s permit to construct and/or install the work herein described. This <br /> application in made in cowliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> 1 " <br /> /-3773 i, e I'lllA2P/hY �. City 650_ OIf J Lot Sime/Acreage <br /> Job Address <br /> Owner's Name 11J1r`j� ! G V! es' MCI <br /> N r L1rffE `> 14� hone�'•7 rJ —'61'l 9 <br /> t , 8421V <br /> Contractor P ddress Z E License No. � Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR IDOTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD_ <br /> etre�c�u.a <br /> FOUNDATION+ AGRICULTURE WELL OTHER WELL 12 X-le'W f 20, <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS oing <br /> tr f <br /> LI Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ ►s- <br /> 1'1 Public rl Other 1. Cl Delta Depth of Grout Seal <br /> I I Irrigation .—.Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump I H.P. State Work Done <br /> Well Destruction ❑ Well.Diameter'# Sealing Material & Depth i <br /> Depth 1 biller Material 4 Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION i I DESTRUCTION l I (No septic system permitted if public sewer is V_ <br /> available within 200 feet.t <br /> Installation will serve: Residence Commercial— Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments C. <br /> PKG. TREATMENT PLT.Ll f Method of Disposal <br /> Distance to.nearest: Well Foundation Property Line �- <br /> LEACHING LINE ❑ No. m Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest Well Foundation Property Line <br /> SEEPAGE PITS Il Depth Size Number <br /> SUMPS LI Distance tb'nssrest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ :( <br /> I hereby certify that i have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin .County <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, !shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting signature <br /> certifies the following: "1 certify that in the'pertormance of the work for which this permit is issued, I shall employ persons subject to workman's <br /> compensa-tion.laws of California." , <br /> The applicant1 call for squired inspections. Complete drawing on reverse side. <br /> Signed X Title: <br /> r=64. 459"w615 Date: <br /> F D ARTMENT USE ONLY <br />} Application Accepted by yt6Date a <br /> Pit or Grout Inspection by �' Date Final Inspection b Date <br /> I Additional Comments: <br />� +r <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> y� Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Boa 2009, Stfrn, CA 95201 <br /> FEE AMOUNT DUE � AMOUNT REMITTED K RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> av a e b I <br /> + EM 1324 IREV,4 95) <br /> EH U-2a <br />